Prior Authorization Denial Appeal Letter Template

Letter Template: Prior Authorization Appeal

[Your Name]
[Your Address]
[City, State ZIP]
[Date]
[Insurance Company Name]
[Prior Authorization Appeals Department]
[Address]
Re: Appeal of Prior Authorization Denial
Member Name: [Your Name]
Member ID: [Your ID Number]
PA Reference Number: [From denial]
Requested Service: [Treatment/Procedure]
Prescribing Provider: [Doctor Name]
Dear Appeals Review Committee:
I am writing to formally appeal the denial of prior
authorization for [specific treatment] dated [denial date].
CLINICAL JUSTIFICATION
[Explain the diagnosis, clinical need, and why this specific
treatment is required. Include previous treatments attempted.]
ADDRESSING THE DENIAL CRITERIA
[The denial cites the following reason:
"[Quote the denial reason]"
I submit the following evidence demonstrating that this
treatment meets coverage criteria:]
[Criterion 1 from denial — your response with evidence]
[Criterion 2 — response]
[Additional criteria addressed]
URGENCY
[If applicable: This treatment is time-sensitive because...
Please process this as an expedited appeal per federal
requirements.]

ENCLOSED DOCUMENTATION
Letter from Dr. [Name] supporting the PA request
[Medical records]
[Lab results/imaging]
[Clinical studies]
I request immediate approval of this prior authorization.

Sincerely,
[Your Name]

PA Appeal Tips

1. Request peer-to-peer review — your doctor can call the insurer's medical director
2. Check for coding errors — sometimes PAs are denied due to incorrect CPT/ICD codes
3. Request expedited review if treatment is urgent (72-hour turnaround)
4. Step therapy exceptions — if PA is denied because you haven't tried a step therapy drug, request an exception
5. Gold card programs — some states/insurers exempt high-approval providers from PA